Gastrointestinal Hemorrhage

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Gastrointestinal Hemorrhage

  1. 1. Gastrointestinal Hemorrhage Carolyn A. Sullivan, MD Pediatric Gastroenterology
  2. 2. Objectives <ul><li>Describe the diagnostic and therapeutic approach to the pediatric patient with GI bleeding </li></ul><ul><li>Review the most common etiologies for GI bleeding in pediatric patients in various age groups </li></ul>
  3. 3. Definitions <ul><li>Melena: passage of black, tarry stools; suggests bleeding proximal to the ileocecal valve </li></ul><ul><li>Hematochezia: passage of bright or dark red blood per rectum; indicates colonic source or massive upper GI bleeding </li></ul><ul><li>Hematemesis: passage of vomited material that is black (“coffee grounds”) or contains frank blood; bleeding from above the ligament of Treitz </li></ul>
  4. 4. History <ul><li>Present illness </li></ul><ul><ul><li>source, magnitude, duration of bleeding </li></ul></ul><ul><ul><li>associated GI symptoms (vomiting, diarrhea, pain) </li></ul></ul><ul><ul><li>associated systemic symptoms (fever, rash, joint pains) </li></ul></ul><ul><li>Review of systems </li></ul><ul><ul><li>GI disorders, liver disease, bleeding diatheses </li></ul></ul><ul><ul><li>Anesthesia reactions </li></ul></ul><ul><ul><li>medications (NSAID’s, warfarin) </li></ul></ul><ul><li>Family history </li></ul>
  5. 5. Physical examination <ul><li>Vital signs, including orthostatics </li></ul><ul><li>Skin: pallor, jaundice, ecchymoses, abnormal blood vessels, hydration, cap refill </li></ul><ul><li>HEENT: nasopharyngeal injection, oozing; tonsillar enlargement, bleeding </li></ul><ul><li>Abdomen: organomegaly, tenderness, ascites, caput medusa </li></ul><ul><li>Perineum: fissure, fistula, induration </li></ul><ul><li>Rectum: gross blood, melena, tenderness </li></ul>
  6. 6. Further assessment <ul><li>Is it really blood? </li></ul><ul><ul><li>Hemoccult stool, gastroccult emesis </li></ul></ul><ul><li>Apt-Downey test in neonates </li></ul><ul><li>Nasogastric aspiration and lavage </li></ul><ul><ul><li>Clear lavage makes bleeding proximal to ligament of Treitz unlikely </li></ul></ul><ul><ul><li>Coffee grounds that clear suggest bleeding stopped </li></ul></ul><ul><ul><li>Coffee grounds and fresh blood mean an active upper GI tract source </li></ul></ul>
  7. 7. Substances that deceive <ul><li>Red discoloration </li></ul><ul><ul><li>candy, fruit punch, Jell-o, beets, watermelon, laxatives, phenytoin, rifampin </li></ul></ul><ul><li>Black discoloration </li></ul><ul><ul><li>bismuth, activated charcoal, iron, spinach, blueberries, licorice </li></ul></ul>
  8. 8. Laboratory studies <ul><li>CBC, ESR; BUN, Cr; PT, PTT in all cases </li></ul><ul><li>Others as indicated: </li></ul><ul><ul><li>Type and crossmatch </li></ul></ul><ul><ul><li>AST, ALT, GGTP, bilirubin </li></ul></ul><ul><ul><li>Albumin, total protein </li></ul></ul><ul><ul><li>Stool for culture, ova and parasite examination, Clostridium difficile toxin assay </li></ul></ul>
  9. 9. Imaging studies and indications <ul><li>Upper GI series : dysphagia, odynophagia, drooling </li></ul><ul><li>Barium enema : intussusception, stricture </li></ul><ul><li>Abdominal US : portal hypertension </li></ul><ul><li>Meckel’s scan : Meckel’s diverticulum </li></ul><ul><li>Sulfur colloid scan, labeled RBC scan, angiography : obscure GI bleeding </li></ul>
  10. 10. Endoscopy: indications <ul><li>EGD : hematemesis, melena </li></ul><ul><li>Flexible sigmoidoscopy : hematochezia </li></ul><ul><li>Colonoscopy : hematochezia </li></ul><ul><li>Enteroscopy : obscure GI blood loss </li></ul>
  11. 11. DDx: neonates <ul><li>Upper GI bleeding </li></ul><ul><ul><li>swallowed maternal blood </li></ul></ul><ul><ul><li>stress ulcers, gastritis </li></ul></ul><ul><ul><li>duplication cyst </li></ul></ul><ul><ul><li>vascular malformations </li></ul></ul><ul><ul><li>vitamin K deficiency </li></ul></ul><ul><ul><li>hemophilia </li></ul></ul><ul><ul><li>maternal ITP </li></ul></ul><ul><ul><li>maternal NSAID use </li></ul></ul><ul><li>Lower GI bleeding </li></ul><ul><ul><li>swallowed maternal blood </li></ul></ul><ul><ul><li>dietary protein intolerance </li></ul></ul><ul><ul><li>infectious colitis </li></ul></ul><ul><ul><li>necrotizing enterocolitis </li></ul></ul><ul><ul><li>Hirschsprung’s enterocolitis </li></ul></ul><ul><ul><li>duplication cyst </li></ul></ul><ul><ul><li>coagulopathy </li></ul></ul><ul><ul><li>vascular malformations </li></ul></ul>
  12. 12. Neonatal stress ulcers or gastritis <ul><li>Causes </li></ul><ul><ul><li>Shock </li></ul></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>Dehydration </li></ul></ul><ul><ul><li>Traumatic delivery </li></ul></ul><ul><ul><li>Severe respiratory distress </li></ul></ul><ul><ul><li>Hypoglycemia </li></ul></ul><ul><ul><li>Cardiac condition </li></ul></ul>
  13. 13. DDx: infants <ul><li>Hematemesis, melena </li></ul><ul><ul><li>Esophagitis </li></ul></ul><ul><ul><li>Gastritis </li></ul></ul><ul><ul><li>Duodenitis </li></ul></ul><ul><li>Hematochezia </li></ul><ul><ul><li>Anal fissures </li></ul></ul><ul><ul><li>Intussusception </li></ul></ul><ul><ul><li>Infectious colitis </li></ul></ul><ul><ul><li>Dietary protein intol. </li></ul></ul><ul><ul><li>Meckel’s diverticulum </li></ul></ul><ul><ul><li>Duplication cyst </li></ul></ul><ul><ul><li>Vascular malformation </li></ul></ul>
  14. 14. DDx: children <ul><li>Upper GI bleeding </li></ul><ul><ul><li>Esophagitis </li></ul></ul><ul><ul><li>Gastritis </li></ul></ul><ul><ul><li>Peptic ulcer disease </li></ul></ul><ul><ul><li>Mallory-Weiss tears </li></ul></ul><ul><ul><li>Esophageal varices </li></ul></ul><ul><ul><li>Pill ulcers </li></ul></ul><ul><li>Lower GI bleeding </li></ul><ul><ul><li>Anal fissures </li></ul></ul><ul><ul><li>Infectious colitis </li></ul></ul><ul><ul><li>Polyps </li></ul></ul><ul><ul><li>Lymphoid nodular hyperplasia </li></ul></ul><ul><ul><li>IBD </li></ul></ul><ul><ul><li>HSP </li></ul></ul><ul><ul><li>Intussusception </li></ul></ul><ul><ul><li>Meckel’s diverticulum </li></ul></ul><ul><ul><li>HUS </li></ul></ul>
  15. 15. Esophageal varices
  16. 16. Erosive esophagitis
  17. 17. DDx: adolescents <ul><li>Hematemesis, melena </li></ul><ul><ul><li>Esophagitis </li></ul></ul><ul><ul><li>Gastritis </li></ul></ul><ul><ul><li>Peptic ulcer disease </li></ul></ul><ul><ul><li>Mallory-Weiss tears </li></ul></ul><ul><ul><li>Esophageal varices </li></ul></ul><ul><ul><li>Pill ulcers </li></ul></ul><ul><li>Hematochezia </li></ul><ul><ul><li>Infectious colitis </li></ul></ul><ul><ul><li>Inflammatory bowel disease </li></ul></ul><ul><ul><li>Anal fissures </li></ul></ul><ul><ul><li>Polyps </li></ul></ul>
  18. 18. NSAID induced ulcers
  19. 19. Peptic Ulcer
  20. 20. Mallory-Weiss Tear
  21. 21. Risk of rebleeding of ulcer <ul><li>Stigmata of recent hemorrhage </li></ul><ul><ul><li>Visible vessel </li></ul></ul><ul><ul><li>Clot </li></ul></ul><ul><ul><li>Spot </li></ul></ul><ul><ul><li>Clean base </li></ul></ul><ul><li>Rate of rebleed </li></ul><ul><ul><li>40-50% </li></ul></ul><ul><ul><li>25-30% </li></ul></ul><ul><ul><li>10% </li></ul></ul><ul><ul><li>2-4% </li></ul></ul>
  22. 22. Ulcer with red spot
  23. 23. Therapy <ul><li>Supportive care : begin promptly </li></ul><ul><ul><li>IV fluids, blood products, pressors </li></ul></ul><ul><li>Specific care </li></ul><ul><ul><li>Barrier agents (sucralfate) </li></ul></ul><ul><ul><li>H 2 receptor antagonists (cimetidine, ranitidine, etc.) </li></ul></ul><ul><ul><li>Proton pump inhibitors (omeprazole, lansoprazole) </li></ul></ul><ul><ul><li>Vasoconstrictors (somatostatin analogue, vasopressin) </li></ul></ul><ul><li>Endoscopic therapy : stabilize and prepare patient first </li></ul><ul><ul><li>Coagulation (injection, cautery, heater probe, laser) </li></ul></ul><ul><ul><li>Variceal injection or band ligation </li></ul></ul><ul><ul><li>Polypectomy </li></ul></ul>
  24. 24. Bleeding Ulcer

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